At the Bombardier Safety Standdown this week, NTSB member Michael Graham emphasized efforts to get more operators to adopt a safety management system (SMS), and not just because it may become a regulatory requirement. An SMS is part of a robust safety program that should include safety reporting, assessment, and flight data monitoring.

Graham cited a series of accidents where lack of safety management played a critical role, including the Kobe Bryant helicopter crash. He also delved deeper into two fatal accidents—the Safari Aviation helicopter air-tour crash in Hawaii in December 2019 and Aeolus Air Charter Challenger 605 accident in Truckee, California, in July 2021.

In the Safari accident, an unusual weather pattern blanketed part of the route with low ceilings and visibility, well below the weather minimums for these flights. The chief pilot, who was flying the accident helicopter, was described by other company pilots as being “safety conscious but also someone who would fly closer to the weather than other pilots,” Graham said. “How do you discover procedural drift? The reactive way is when my agency shows up. We always get calls when things go bad.”

The Challenger 605 accident involved a circle-to-land maneuver with two pilots who were flying together for the first time. There was no briefing of the circling approach. For unknown reasons, the pilots selected flaps 45, which results in spoiler deployment, even though flaps 30 is the correct setting for maneuvering flight. Another problem was that the pilots were using the incorrect basic empty weight, which was 3,000 pounds lighter than the actual empty weight. This resulted in the landing reference speed of 118 knots being six knots slower than it should have been.

But the circling maneuver didn’t resemble a normal downwind, base, and final turn. While the pilots were trying to line up with the runway, the Challenger’s stick shaker then pusher activated and pitched the nose down. They deactivated it, but then the elevator pitched up 18 degrees, and the shaker and pusher activated again as the Challenger’s left wing stalled and the airplane crashed short of the runway.

The Challenger’s operator was a new Part 135 charter company, although this flight was not a charter and was flown under Part 91. The company had neither an SMS nor a flight data monitoring program.

In its Most Wanted list, the NTSB has asked the FAA to mandate SMS for all revenue-carrying passenger operations, in addition to requiring operatorsto implement a flight data monitoring program. Of the 2,000 or so charter operators in the U.S., only a few dozen have adopted an SMS under the FAA’s voluntary program. Graham also pointed out that Part 91 operators could benefit from adopting SMS.

“Why didn’t Safari have an SMS?” he asked. “They said it was due to the size and scope of their operation. We hear this over and over again. I’m concerned about that. Small operators mistakenly believe an SMS is overly burdensome. We must change the perception. People know about the known risks. Failure to identify previously unknown risks increases the likelihood of an incident or accident.”


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